【作者】 曹学冬； 王亚农； 朱蕙燕； 莫善兢； 蔡宏； 吴江宏； 徐宇；

【Author】 Cao Xue-Dong Wang Ya-Nong Zhu Hui-Yan Mo Shan-Jing Cai Hong Wu Jiang-Hong Xu yu

【机构】 复旦大学附属肿瘤医院；

【摘要】 目的:观察全胃切除术后间置空肠及十二指肠前后双储袋成形术的临床疗效,并与Roux—en—Y空肠单储袋重建术进行比较,明确其在胃恶性肿瘤治疗中的地位和优越性。方法:收集50例需全胃切除的病人,随机分成两组,试验组和对照组各25例。试验组:全胃切除术后间置空肠及十二指肠前后双储袋成形术:在距曲氏韧带下25cm处切断空肠,将远侧一段60—65cm的空肠远侧段折合后行侧侧吻合,形成 10cm长的空肠储袋(Pouch 1),再将该段空肠顺行置入食道和十二指肠之间,分别与食道和十二指肠吻合,食道-空肠吻合A和十二指肠-空肠吻合B采用管状吻合器吻合,使AB 段成为间置空肠。然后在曲氏韧带下近侧段空肠与远侧段空肠作一远段对近端的大的侧侧吻合,即储袋式吻合(Pouch 2),吻合口宽10cm。两空肠储袋均采用侧侧吻合器吻合,两个Pouch间空肠不切断,以粗丝线结扎该处肠管, 对照组: 全胃切除术后Roux-en-Y空肠单储袋重建术。术后3、6、 12、24个月复查,观察比较近、远期并发症和营养状况及 Visick分级。结果:目前已对38例胃癌患者行全胃切除,其中试验组17例,对照组21例。手术情况:手术平均耗时3小时20分钟, 术中出血量27例(71％)<100ml,7例(18％)100- 250ml,4例(11％)>250ml。手术清扫范围35例行D2,3例 D3清扫术,清扫淋巴结总数4—44个,平均21个,转移淋巴结总数0—37个,平均9个。两组之间无统计差别。术后情况: 目前死亡6例,皆死于复发,其中试验组2例。术后无吻合口漏、吻合口出血、肠梗阻等并发症。66．7％的患者术后化疗, 其中试验组86％化疗,对照组53％,两者有统计学差异。术后3个月试验组单餐进食量和每天进食总量都比对照组高,单餐74％VS 65％,总量83％VS 77％, 倾倒综合征试验组1 例(7％)对照组3例(16％),碱性返流性食管炎试验组无,对照组1例(5％),白蛋白和转铁蛋白比术前升高。术后六个月两组进食量接近,单餐73％,总量80%,试验组体重比术后三个月平均上升0．2kg,而对照组仍在下降,平均0．5kg,血红蛋白试验组比术后三个月平均上升7．86g,而对照组仍在下降,平均2．68g,另外白蛋白、前白蛋白都比术后三个月升高, 而对照组仍在下降,转铁蛋白两组都升高,且试验组更高。术后六个月两组都无Roux—Y滞留综合征和吻合口狭窄,倾倒综合征试验组无,对照组3例(20%)。试验组无返流性食管炎,对照组2例(13％)轻度返流性食管炎。上消化道造影可见双储袋有一定的食物储留功能。Visick分级I级82％,II级 18％。结论:目前研究发现全胃切除术后间置空肠及十二指肠双储袋成形术可以减少患者术后并发症及提高患者营养状况, 该术式的长期效果有待进一步随访观察。更多还原

【Abstract】 Objective: Introduce a new type reconstruction after total gastrecyomy. Evaluate the clinical effect of the reconstruction and compare it with Roux-en-Y with a single pouch reconstruction. Materials and Methods: A total of 50 patients with gastric malignant tumor were collected and randomly divided into double jejunojejunai pouches group (DP) and Roux-en-Y group (RY), 25 patients for each group. Jejunal interposition and double jejunojejunai pouches reconstruction: Cut the jejunum at the 25cm distal from the Treitz ligament after removing the stomach, the distal 60-65cm length jejunum was folded and side-to-side jejunojejunostomy was done with a linear stapler at the antimesenteric border. Apical bridge, which had no side-to-side anastomotic lesion, was adjusted to 2-3 cm, and the length of the pouch was 10 cm (pouch 1), then the jejunal pouch was located between esophagus and duodenum. The esophagus and the jejunum were anastomosed by an end-to-end technique, the apical bridge was anastomosed to the duodenum by an end-to-side technique using a circular stapler. Then the proximal and dis- tal jejunum were anastomosed by a side-to-side technique using a linear stapler near the Treitz ligament (pouch 2). Ligate the jejunum between the two pouches with silk suture without cutting it. Roux-en-Y with a single pouch reconstruction: Cut the jejunum and construct an end-to-end or end-to-side esophago-jejunostomy using distal jejunum after removing the stomach, then the proximal and distal jejunum were anastomosed by a side-to-side technique using a linear stapler to make a pouch about 10cm in length. At 3,6,12,24 months after surgery, patients in the two groups were compared for problems in gastrointestinal function, complications, quality of life, improvement in body weight and nutritional parameters, serum albumin and hemoglobin level. Results: Up to now, 38 patients have undergone total gastrectomy, 17 in DP group and 21 in RY group.2 patients have died of the recurrence of gastric cancer in DP group and 4 in RY group. There are no anastomotic leakage, anastomotic hemorrhage and intestinal obstruction. At 3 months after surgery ,the food-intake quantity in DP group is larger than RY group(one meal 74% VS 65%, total of one day 83% VS 77%). In the DP group, 1 patient (7%) had dumping syndrome and nobody had regurgitation or diarrhea. While in the RY group, there were 3 patients (16%) with dumping syndrome, 1 patient (5%) with regurgitation and no patient with diarrhea. Albumin and transferrin increased in both groups. At 6 months after surgery, the food-intake quantity was about equal (73% for one meal and 80% for total of one day). Compared with 3 months after surgery, the body weight increased 0.2kg in DP group, while decreased 0.5kg in RY group on average. Besides, albumin and prealbumin levels were higher than those at 3 months after surgery in DP group, while they still decreased in RY group. In both group, transferrin level was increased更多还原